Provider Demographics
NPI:1528233228
Name:WAGNER, KAREN S (MED, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:S
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MED, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:587 SHIRLEY LN NE
Mailing Address - Street 2:
Mailing Address - City:PIEDMONT
Mailing Address - State:OK
Mailing Address - Zip Code:73078-4239
Mailing Address - Country:US
Mailing Address - Phone:405-290-8646
Mailing Address - Fax:
Practice Address - Street 1:587 SHIRLEY LN NE
Practice Address - Street 2:
Practice Address - City:PIEDMONT
Practice Address - State:OK
Practice Address - Zip Code:73078-4239
Practice Address - Country:US
Practice Address - Phone:405-290-8646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-24
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2992235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist